New evidences aroused in treatment of ischemic stroke from early 2015. Large and well conducted trials demonstrated the benefit of endovascular therapy (in association with thrombolysis) on primary clinical endpoints.

Today AHA and ASA updated the 2013 Stroke Guidelines for the Early Management of Patients With Acute Ischemic Stroke regarding Endovascular Treatment on the basis of this recent evidences.

Let’s resume the recommendations on Endovascular Interventions:

Patients who are elegible for intravenous r-tPA should receive r-tPA and in addition endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):

Prestroke modified Ranking Scale score 0 to 1

Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies

Treatment can be initiated (groin puncture) within 6 hours of symptom onset

To ensure benefit, reperfusion should be achieved as early as possible and within 6 hours of stroke onset (Class I; Level of Evidence B-R). (Revised from the 2013 guideline); if treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain (Class IIb; Level of Evidence C). (New recommendation)

The benefits are uncertain, on carefully selected patients with acute ischemic stroke in whom treatmentcan be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries. (Class IIb; Level of Evidence C). (New recommendation)

Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset, but the benefits are not established in this age group (Class IIb; Level of Evidence C). (New recommendation)

And here we are with the 3th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:

In this episode we’ll explore the best articles of 2014 about:

Trauma

Before approaching specific arguments about trauma here are some fundamental articles to read about new emerging concepts in trauma care. Those are the clinical and physiological bases to understand what is happening in the actual trauma management scene.

The second episode of this focus reviews will deeply assess a topic that is very “hot” for every emergency professional.

Before reading this episode give a look at the first of the series about the best of 2014 literature on Cardiac Arrest

And now enjoy the very best of 2014 articles on:

Airway Management

Not all is CRASH! Especially when it comes to airway management. RSI is the gold standard when we talk about intubating a spontaneously breathin patient but DSI is becoming a classic. And is recommended by Scott Weingart and Seth Trueger, not properly two “new kids on the block”….

This disclaimer should be written on the handle of every laryngoscope to remember two of the most frequent fault to avoid when managing the airways.

Always rewarded as a nightmare for the emergency professional, surgical airway is most of the time a real no through road for the patient. So here is a complete guide on how to approach in the best way such a difficult skill.

Does the aggressive management of the airways gets benefits on critically ill patients or a more conservative approach gives best results on clinical outcomes? Facts (few) and doubts (many) in this year literature.

This is the first (of a series) of literature reviews dedicated to a particular topic of Emergency Medicine clinical life.

We tried to give a deep look to all the articles that had a relevance for a particular argument in this year, and made some considerations regarding the emerged evidences . All the articles are full text end ready to be downloaded.

The first edition is focused on the “king argument” for an emergency medicine and critical care professional:

Cardiac Arrest

Chest compressions

This year the importance of chest compressions in CA was confirmed and even emphasized as one of the few (along with defibrillation) really wothy intervention to perform during CPR.

Mechanical Devices

The “black year” for mechanical devices saw 3 major trials finding no difference in outcome between mechanical and (good quality) manual chest compressions. Still remains the subjective (personal) impression that mechanical devices are of some utility for the human resources management and transport during CPR.

Vasoactive (and other) drugs

Like (and perhaps more) than for mechanical devices, 2014 signed a really bad year for epinephrine.

Lack of evidence on his utility and emerging ones on detrimental effects, accompanied this “historical” drug through the year that preludes to new 2015 CA Guidelines. Will epinephrine still be there at the end of this 2015? Or new emerging trends on use of steroids and vasopressin will prevale at the end?

ECLS

And after interventions that are loosing evidence in the years, new future prospectives for the management of CA patients, comes from Extra-Corporeal Membrane Oxygenation that gives renewed hopes of better survival and good neurological outcome, despite initial difficulties and skepticism.

Therapeutic Hypothermia

New era for the post-resuscitative care! Less oxygen, lower tidal volume and last, but not least, less cooling. And, while this year will give us some answers about intra-arrest cooling, now we know that 33°C is equally effective as 36°C and is no longer recommended in post ROSC patients! Maybe….